Monday and non-Monday concentrations of lifestyle-related blood components in the Oslo Diet and Exercise Study

CONTEXT: Despite intense debates about legalization, there are few data examining the details of actual euthanasia and physician-assisted suicide (PAS) cases in the United States. OBJECTIVE: To determine whether the practices of euthanasia and PAS are consistent with proposed safeguards and the effect on physicians of having performed euthanasia or PAS. DESIGN: Structured in-depth telephone interviews. SETTING AND PARTICIPANTS: Randomly selected oncologists in the United States. OUTCOME MEASURES: Adherence to primary and secondary safeguards for the practice of euthanasia and PAS; regret, comfort, and fear of prosecution from performing euthanasia or PAS. RESULTS: A total of 355 oncologists (72.6% response rate) were interviewed on euthanasia and PAS. On 2 screening questions, 56 oncologists (15.8%) reported participating in euthanasia or PAS; 53 oncologists (94.6% response rate) participated in in-depth interviews. Thirty-eight of 53 oncologists described clearly defined cases of euthanasia or PAS. Twenty-three patients (60.5%) both initiated and repeated their request for euthanasia or PAS, but 6 patients (15.8%) did not participate in the decision for euthanasia or PAS. Thirty-seven patients (97.4%) were experiencing unremitting pain or such poor physical functioning they could not perform self-care. Physicians sought consultation in 15 cases (39.5%). Overall, oncologists adhered to all 3 main safeguards in 13 cases (34.2%): (1) having the patient initiate and repeat the request for euthanasia or PAS, (2) ensuring the patient was experiencing extreme physical pain or suffering, and (3) consulting with a colleague. Those who adhered to the safeguards had known their patients longer and tended to be more religious. In 28 cases (73.7%), the family supported the decision. In all cases of pain, patients were receiving narcotic analgesia. Fifteen patients (39.5%) were enrolled in a hospice. While 19 oncologists (52.6%) received comfort from having helped a patient with euthanasia or PAS, 9 (23.7%) regretted having performed euthanasia or PAS, and 15 (39.5%) feared prosecution. CONCLUSIONS: Intractable pain or poor physical functioning seem to be nearly absolute requirements for physicians to perform euthanasia or PAS. Only one third of cases are performed consistently with proposed safeguards. For some patients, end-of-life care that includes opioid analgesia and hospice care does not obviate their desire for euthanasia or PAS. While the majority of physicians seem comforted by their actions, some experience adverse consequences from having performed euthanasia or PAS.     

A public health perspective on "The ethics of asking and not asking about abuse."

Comments on the article by K. Becker-Blease and J. Freyd (see record 2006-03947-003), which provides a thought-provoking and important perspective regarding the ethics of researchers asking or not asking adults about abuse they experienced as children. Many of these authors' concerns with research on abuse during childhood apply equally to abuse and violence experienced at all life stages. Focusing on intimate partner violence (IPV), we wish to amplify upon and respond to their observations from the perspective of public health scientists involved in large-scale telephone survey research on violence (including family violence, IPV, sexual violence, and suicide). We strongly agree with Becker-Blease and Freyd that decisions not to ask about abuse play directly into the social forces that perpetuate IPV and other forms of violence as pervasive and pernicious social and public health problems. From a public health perspective, the question is not whether to ask but how to ask about participants' experiences with violence and abuse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Venlafaxine''s effects on healthy volunteers'' driving, psychomotor, and vigilance performance during 15-day fixed and incremental dosing regimens

Patients, providers, and families are increasingly involved in end-of-life decisions (advance directives, health care proxy, do-not-resuscitate [DNR] status consents). These decisions can be complex processes whereby the participants in the process must come to terms with often painful and difficult decisions. The role perception of the nurse in end-of-life decision making is not well delineated. This chapter explores the results of a study that addresses the question, "What are the experiences of oncology nurses as they interact with patients and/or family members during the process of patients/families signing DNR consents. The grounded theory method of data collection and analysis was used to explore this question. The results of the study indicate that central to the process of consenting to DNR status is the degree of shared understanding about the meaning of DNR status among participants and the conflict that can occur when meanings are not shared. A model is presented that illustrates the connections between the meanings of DNR (patient, family, and provider) and congruence and conflict in the DNR consent process. Strategies are discussed that facilitate prevention or resolution of conflict in the DNR status decision-making process. Strategies used by the nurse to facilitate decision making by patient and families include communicating with, caring for, educating, advocating for, and collaborating with patients, families, and other providers.     

Unnecessary emergency transport and care of grand mal seizures

Every source quoted in this study has clearly refuted the need for emergency transport and care of an uncomplicated grand mal seizure in a managed epileptic patient. This review of a large patient population has determined that 27% of emergency department seizures were uncomplicated and occurred in patients already under care. This represented 0.25% of all emergency department visits and nearly $200,000 in claims to this managed care entity per year. Taking some statistical liberties, a national health care expenditure of $270,000,000 is suggested for this single abuse. It is hoped that further education of the public, medical community, and epileptic patients will produce a comfort level that permits decisions about emergency transport and care of seizures. These savings could translate into basic health insurance for thousands of our medically deprived citizens.     

Palliative care in undergraduate medical education. Status report and future directions

OBJECTIVE: To describe the status of palliative care education in the undergraduate medical curriculum and to offer recommendations for improvement. DATA SOURCES: Review of literature on palliative care and of recently submitted grants on medical education for end-of-life care. STUDY SELECTION: English-language reports of educational programs targeted toward medical students were examined, as well as surveys of medical schools. DATA EXTRACTION: Studies were reviewed by the authors to assess the quality of the educational program, evaluation methodology, and conclusions. From over 9000 citations on palliative care and related topics that were retrieved from MEDLINE searches from 1980 through 1995, and from reviewing 14 palliative care journals published from 1985 through 1996, 310 articles were identified that addressed medical education for end-of-life care, and 180 were carefully examined. DATA SYNTHESIS: While nearly all medical schools offer some formal teaching about end-of-life care, there is considerable evidence that current training is inadequate, most strikingly in the clinical years. Teaching about palliative care is received favorably by students, positively influences student attitudes, and enhances communication skills. However, curricular offerings are not well integrated; the major teaching format is the lecture; formal teaching is predominantly preclinical; clinical experiences are mostly elective; there is little attention to home care, hospice, and nursing home care; role models are few; and students are not encouraged to examine their personal reactions to these clinical experiences. CONCLUSIONS: The increasing attention to palliative care education has created major opportunities for improving education about care at the end of life. Educational programs should be rigorously evaluated to identify best educational practices.     

Advance directives and advocacy in end-of-life decisions

This article examines the issue of advocacy for all adults in end-of-life decisions to help enhance the role of health care providers as partners in decision making. The ethical issues of death and dying are of particular concern for the elderly. Conflicts may prevent providers and nurses from creating a good dying experience for patients and family. Among the many issues associated with end-of-life decision making are futility, autonomy, and quality of life, a "good death," advance directives, family distress, and the culture of medicine. To overcome related barriers, involved health care providers can promote advocacy by offering choices in end-of-life care and providing an environment of listening and communication. Initiating and maintaining dialogue on this difficult subject will provide better care to patients and families.     

A sequence in the 5'' flanking region confers progestin responsiveness on the human c-myc gene

Sarcoidosis is a systemic granulomatous disease of undetermined etiology in which the immune system is overstimulated. Management of the patient with sarcoidosis entails continuity of patient care far beyond disease, even into remission. Care is comprehensive, including all involved organ systems, coordination of specialty consultations and services, and includes diagnostic tests. Therapeutic decisions are the responsibility of the primary care practitioner. Prognosis of sarcoidosis is not uniformly good. Patients can die. Subacute sarcoidosis patients usually do not require pharmacologic therapy. Chronic sarcoidosis may require long-term treatment for years to indefinitely. Corticosteroids are still the drugs of choice and other therapy is now available. Health organizations and private nonprofit support groups are available for patient education and assistance. Close support must still come from the family unit. Sarcoidosis may occur in family members in different cohorts at all ages in life and in any racial or ethnic group. The second in a two-part series on management of the patient with sarcoidosis, this article describes coordination of care and considers community, prevention, and family aspects of the disease.     

The registered nurse: perceptions about advance directives

The driving force behind mandates from both the American Nurses' Association and the American Medical Association is an expectation that doctors and nurses will act as advocates for the participation of the patient in end-of-life treatment decisions. This mandate assumes that both groups are knowledgeable about advance directives and can advise patients on these. Both groups are enjoined not only to facilitate the expression of the patient's wishes but also scrupulously to honor these. The literature suggests that, despite their professional mandate, nurses may feel uncertain about the legal, moral, and ethical obligations surrounding their participation in this enormously significant aspect of patient care. This study focuses on the perception of the dilemma by a sample of registered nurses at a large southeastern university medical center.     

End-of-life algorithms.

Tools and strategies for eliciting patient preferences for end-of-life care are often absent, of poor quality, or ignored. The American Medical Association's Council on Ethical and Judicial Affairs has proposed new guidelines for the "optimal use" of advance directives. The guidelines urge the use of detailed work sheets in "tailoring end-of-life care to patients' preferences" and suggest a process to be followed by physicians in educating patients about death and dying. However, these well-intentioned guidelines face 3 key obstacles: the negative consequences of "ritualizing" end-of-life planning, physicians' inclination to disdain and to delegate to others communication about end-of-life preferences, and the tardiness of medical pedagogy in emphasizing end-of-life care and communication as crucial for the success of future physicians. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The role of the psychologist in determining competence for assisted suicide/euthanasia in the terminally ill.

This paper discusses the history of assisted suicide/euthanasia and public attitudes in Canada; discusses depression in the terminally ill and the potential role of the psychologist in the assisted suicide/ euthanasia process; and specifically addresses the importance of determining competence in terminally ill patients. One area in which the services of psychologists have not been used to their fullest potential is in the care of the terminally ill, particularly in helping them make end-of-life decisions. It is very important that individuals making end-of-life decisions be assessed for mental disorders in order to ensure they are able to make competent decisions. If assisted suicide and euthanasia were to become legalized, psychologists should be involved in the assessment process in order to determine competency. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

End-of-life confusion in patients with cancer

PURPOSE/OBJECTIVES: To review the literature on confusion at the end of life, provide accurate definitional and defining characteristics of confusion, and outline nursing strategies for its resolution. DATA SOURCES: Published articles, computerized databases, book chapters, reference lists from chapters and journal articles. DATA SYNTHESIS: As a major component of symptom distress in terminal care, confusion has not been defined clearly and therefore has not benefited from rigorous assessment and study as have other end-of-life symptoms. CONCLUSIONS: Increased knowledge about confusion that occurs in patients with widely metastatic cancer will assist in accurate symptom identification, early recognition, and timely management to reduce cognitive symptom distress at the end of life. Improved symptom resolution also can benefit family coping during terminal care. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses can devise management protocols for confused patients that include screening criteria, pharmacologic interventions, environmental support, and prophylactic safety measures.     

Transition from paediatric to adult-orientated care for adolescents with cystic fibrosis

Adolescence is a time of major physical and psychological change. Young teenagers need to become comfortable with their developing sexuality, to begin moving towards independence with a greater reliance on peer group acceptance, to face the future and to make important decisions about their education, career and goals. Difficulties inherent in all of these steps to adult life are magnified by chronic ill health. It is harder for adolescent patients to break family ties, harder to feel accepted by their peer group, harder to plan realistically for the future. It must be the overriding aim of the professional health carers to encourage these patients to confront the problems of adolescence and to help them maintain their physical and emotional stability throughout this challenging period. Parents also must be supported, and encouraged gradually to devolve to their child responsibilities for decision making and for taking prescribed medication. A planned and sensitive transition from a paediatric to an adult health-care system will aid a successful evolution to an independent adult life. The paediatric hospital environment is not best equipped to deal with the problems of adolescence. Just as parents must allow their child to move on, so the paediatric caring team must loosen its ties with the patient and allow transfer to the adult team. There are several ways of effecting this transfer of care. None of them is proven to be better than any other, but the transfer should always be planned, smooth, efficient and expected by the patient. Ideally, all patients should have the opportunity to transfer to a properly equipped and properly staffed adult cystic fibrosis centre where they can continue to receive the highest standards of care from an experienced multidisciplinary team.     

Information system support of changes in health care and nursing practice

The practice of nursing is changing in response to changes in health care. An effective information system can support nursing's need to streamline the process of documentation, move to standards-based practice, access standards and other reference material, and access data and information to make clinical and management decisions. Nurses will increasingly rely on information systems to provide them with the critical data and information they need to make decisions about patient care, management of the care team, efficient resource utilization, and best practice standards.     

Roles for Psychologists in End-of-Life Care: Emerging Models of Practice.

Professional psychologists are increasingly likely to encounter opportunities to work with patients and families facing end-of-life issues. Psychologists can provide psychological assessment, intervention for patients and families, consultation with and support of health care team members, grief therapy, and program development and evaluation. Psychological services are useful for healthy individuals who wish to make thoughtful plans about their own future care, patients with life-limiting illnesses, families stressed by providing end-of-life care, bereaved individuals, and health care providers who face issues of burnout and strain. Several challenges for psychologists working in end-of-life care are noted, including training, development of clear roles, and reimbursement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What is wrong with end-of-life care? Opinions of bereaved family members

OBJECTIVE: To describe family perceptions of care at the end of life. METHODS: In a representative sample of older people who died from chronic diseases, family members were interviewed about satisfaction with treatment intensity, decision-making, and symptom relief in the last month of life, and gave suggestions to improve care. RESULTS: Interviews were completed with 461 family members, 80% of those contacted. They reported that 9% of decedents received CPR, 11% ventilator support, and 24% intensive care during their last month of life. Family members could not recall a discussion of treatment decisions in 23% of cases. Presence or absence of a living will did not affect the likelihood of no discussion (22% vs 24%, P = .85). Family informants desired more treatment to sustain life in 8% of deaths. They or the decedent wanted treatments doctors did not recommend in 6% of deaths but refused recommended therapies in 18% of deaths. They believed more care to relieve pain or other symptoms was indicated in 18% of deaths. Asked to make positive or negative comments about any aspect of terminal care, 91% of comments on hospice were positive. Nursing home care received the smallest proportion of positive comments (51%). Family members recommendations to improve end of life care emphasized better communication (44%), greater access to physicians' time (17%), and better pain management (10%). CONCLUSION: Bereaved family members are generally satisfied with life-sustaining treatment decisions. Their primary concerns are failures in communication and pain control. Discussions that focus on specific treatment decisions may not satisfy the real needs of dying patients and their families.     

Dying to pay: the cost of end-of-life care

The number of elderly Canadians is likely to double in 20 years, spurring a discussion of end-of-life care. We analyze the literature on the costs of this care and compare cost assessments of different models of palliative care. The cost of treatments for which there is little empirical support is factored into our cost-savings analysis and the methodological limits of cost-analysis studies are also discussed. We conclude that (a) depending upon the model of care, costs of end-of-life care are considerable, (b) costs of care become more expensive with distance from the home setting, (c) cost savings reported in palliative care settings may be a function of nearness to death; (d) family expenses on end-of-life care are substantial and are not factored into most cost-analysis studies, (e) a two-tiered system of palliative home care allows families with higher incomes to afford help in supporting home deaths, and (f) some treatments given to dying patients are costly while yielding little benefit.     

Legal and ethical considerations of informed consent

The law of informed consent remains ineffective at resolving patient comprehension issues primarily because differing interpretations exist regarding who is responsible for the duty to inform. Court cases continue to set precedents for practicing physicians and other health care providers; however, other measures can be applied for effectual patient advocacy. Health care personnel should rewrite typical consent forms in simpler terms, use larger print, and create duplicate copies. If patients are given copies of the permits they sign, the can reread the forms at home when they are more comfortable. For true autonomy to exist in informed consent for surgical procedures, consent forms should contain patients' primary languages whenever possible, or an adequate interpreter should be made available. Surgeons, nurses, and other health care providers must become aware of their responsibilities related to informed consent for treatment. It is necessary for health care personnel to develop and use effective communication techniques and remember that although some patients are more visually attuned to new information, other patients may benefit more from listening or reading. The cases in this article show that a patient's autonomy is part of the informed consent process and the duty to inform the patient lies with the person performing the procedure. A more important issue, however, involves the patient's comprehension of the information given, because without it, the patient cannot achieve true autonomy in making decisions. Ensuring that all elements of informed consent are met to obtain informed consent will result in fewer malpractice claims, greater patient satisfaction, and an improved professional image. Nevertheless, nurses should make themselves aware of the state laws in which they practice, including their nurse practice acts. They then should advocate for patient rights by encompassing all elements of informed consent.     

Medical specialists prefer to withdraw familiar technologies when discontinuing life support

OBJECTIVE: To assess how members of different specialties vary in their decisions about which form of life support to withdraw. The hypothesis was that each specialty would be more comfortable withdrawing its "own" form of life support relative to other forms and other specialties. DESIGN: Mail survey. SETTING: 24 medical centers. PARTICIPANTS: 225 specialists in six specialties and 225 comparison physicians randomly matched according to percentage of time devoted to clinical practice. MEASUREMENTS: The six specialties were linked with six life-sustaining technologies related to their special expertise: 1) pulmonologists with mechanical ventilation, 2) nephrologists with hemodialysis, 3) gastroenterologists with tube feedings, 4) hematologists with blood products, 5) cardiologists with intravenous vasopressors, and 6) infectious disease specialists with antibiotics. The subjects ranked different forms of life support in the order in which they would prefer to withdraw them. They also expressed their preferences in response to hypothetical clinical vignettes. RESULTS: In five of the six specialties, the specialists had a relative preference for withdrawing their "own" form of life support, compared with the preferences of the comparison physicians. Overall, the physicians tended to prefer withdrawing a form of life support closely linked with their own specialty. CONCLUSIONS: Just as some specialist physicians tend to reach for different technologies first in treating patients, they also tend to reach for different technologies first when ceasing treatment. Specialists' preferences for different ways to withdraw life support not only may reflect a special understanding of the limits of certain technologies, but also may reveal how ingrained are physicians' patterns of practice.     

A report of an investigation of end-of-life care practices in health care facilities and the influences on those practices

In 1992, 82.2% of deaths in Alberta occurred in acute care hospitals or continuing care facilities. This paper outlines the end-of-life care of adult inpatients who died that year in four such facilities (n = 137). CPR was an infrequent end-of-life treatment modality (2.9%), in stark contrast to the extensive use of other medical technologies. Almost every inpatient (94.2%) died with one or more technologies in continuous operation. Although reasons were infrequently given, the desire to promote patient comfort was the most frequent influence on end-of-life technology use. The findings of this study raise issues for debate and further investigation. Chief among these issues is whether or not medical technologies promote comfort during the dying process.     

Advances in hospice care

Hospice care developed in part as a reaction to the impersonal and technology-dependent end-of-life care offered by modern medicine. Unique approaches to care that emphasize interdisciplinary team management of troublesome symptoms and the promotion of quality of life as defined by the patient, are finding their way into all aspects of health care. Symptom control measures have expanded to include chemotherapy, radiation therapy, and multimodal therapies. Both the development of a unique knowledge base and advances in research have fostered the integration of hospice and palliative care into mainstream medicine.